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1 Tenants and Leaseholders Home Contents Insurance Scheme Application Form (Subject to the terms, exclusions and conditions of the policy, a specimen of which is available on request). Before you fill in the form, read the declaration at the end. Make sure that you answer all the questions as fully as possible. Please return the whole completed to the Council. Please keep a copy of this form together with any information you send with it. Or you can ask for a copy from the insurance company within three months of taking out insurance. This form is used to work out your insurance premium and whether you can be insured. Please include all information. If you are in any doubt about whether to include information, please include it. If you do not it may mean that any claim you make is turned down. Your Full Name (Mrs, Ms, Miss, Mr, other) (The person(s) to be insured).. Address Post Code.. Telephone no Date of Birth If you are over 60, please tick box Your Job (Please state if retired) Are you a Tenant or a Leaseholder of the Council? Yes No Required start date (Must be a Monday)..

2 The Amount of Insurance Required (your sum insured) to the nearest 1, Do you require Accidental Damage Cover? Yes No If you have a spouse or partner living with you, please complete the following questions about them: Their Full Name Date of Birth.. Their Job Insurance starts when Bristol City Council informs you that you have been accepted onto the scheme. You will be sent a policy booklet and schedule which will confirm the sum insured, premium and start date. It is important that the sum insured chosen (in round sums of 1000) is sufficient to cover the full replacement cost of all your household goods and personal effects. Please answer all the questions below. We can only consider your application once these questions have been answered. Please use capital letters when filling in this form. To be completed by the applicant (Please tick the correct box in answer to the questions below). We can only consider your application once all these questions are answered in full. Yes No 1. Is your home self-contained with its own separate lockable front door? 2. Is this property your permanent home and occupied only by yourself and members of your immediate family normally living with you? 3. Does the amount of insurance you have chosen cover the full cost of replacing all your household goods and personal belongings? If you have answered no to any of the above questions, please give more details below (Use a separate sheet if more space is needed)..... Yes No 4. Do you regularly leave your home empty or unattended for more than 60 days? 5. Is your home used for running a business? 6. Have you or anyone living with you ever been refused insurance, had insurance cancelled or had special terms imposed by an insurer?

3 If you have answered yes to any of the above questions, please give more details below (Use a separate sheet if more space is needed)..... Yes No 7. Have any incidents occurred in the last five years which would have caused you to make a claim for household contents or personal effects, whether or not you were insured at the time? If you answered yes to the above question, please give us the following information (Use a separate sheet if more space is needed). Date(s) of incident(s) What caused the loss (theft, water damage etc.)?. Value of the goods lost or damaged. Were you insured at the time?... If so, how much did the insurers pay in settlement of the claim?. 8. If you have had a burglary in the last five years, please state How entry was gained? What additional security has been installed since the incident? (Extra locks, alarms etc.) 9. Have you or anyone living with you ever been convicted or charged with any offence, other than motoring offences, or is any prosecution or police enquiry pending? Yes No If you answered yes to the above question, please tell us: Date of conviction or charge... Nature of offence.. Penalty received (amount of fine, length of sentence etc.) Your age at the time.

4 Important Notice: Material Facts All material facts must be disclosed. Failure to do so could invalidate the policy. A material fact includes any questions you are asked to provide answers to and any assumptions you agree to when you take out the policy, including anything that appears within your application form and, or your Schedule, such as intended unoccupancy of your property, or if any member of your household is charged with, cautioned for or convicted of a criminal offence (other than motoring offences). If you are in any doubt as to whether a fact is material then it should be disclosed to the insurer. If any changes in material fact arise during the period of insurance cover please contact your administrator. We recommend you keep a record (including copies of letters) of all information provided to the insurer for your future reference. A copy of the completed application form will be supplied on request within a period of three months after it s completion. A specimen copy of the policy booklet is available on request. Please read the declaration below carefully before signing it Declaration I, We understand the contents of this completed application and I, We declare that the information given is, to the best of my, our knowledge and belief correct and complete. If the risk is accepted I, We undertake to pay the premium when called upon to do so. I, We understand that my, our information may also be disclosed to regulatory bodies for the purposes of monitoring and, or enforcing the insurer s compliance with any regulatory rules, codes. I, We have read the information overleaf under the heading Important Information. You must declare the full value of goods or property insured. Failure to do so may invalidate your policy or reduce claims settlements. Applicant signature(s) Joint applicants should sign unless they are married to each other. Date Special note If during the period of your insurance cover, your home is likely to be unoccupied (e.g. through hospitalisation, extended holiday) for more than 30 consecutive days you will have to advise Bristol City Council.

5 For Official Use Only Date received Premium Policy No Start Date... Important Information Data Protection Act: Information Uses For the purposes of the Data Protection Act 1998 the Data Controller in relation to any personal data you supply is Aviva Insurance Limited. Fraud Prevention and Detection In order to prevent and detect fraud we may at any time: Share information about you with other organisations and public bodies including the Police. Undertake credit searches and additional fraud searches. Check and, or file your details with fraud prevention agencies and databases, and if you give us false or inaccurate information and we suspect fraud, we will record this. We can supply on request further details of the databases we access or contribute to. We and other organisations may also search these agencies and databases to: Help make decisions about the provision and administration of insurance, credit and related services for you and members of your household. Trace debtors or beneficiaries, recover debt, prevent fraud and to manage your accounts or insurance policies. Check your identity to prevent money laundering, unless you furnish us with other satisfactory proof of identify. Insurance Administration Your information may be used for the purposes of insurance administration by the insurer, its associated companies and agents, by reinsurers and your intermediary. It may be disclosed to regulatory bodies for the purposes of monitoring and, or enforcing the insurer s compliance with any regulatory rules, codes. Your information may also be used for research and statistical purposes and crime prevention. It may be transferred to any country, including countries outside the European Economic Area for any of these purposes and for systems administration. Where this happens, we will ensure that anyone to whom we pass your information agrees to treat your information with the same level of protection as if we are dealing with it.

6 If you give us information about another person, in doing so you confirm that hey have given you permission to provide it to use and for us to be able to process their personal data (including any sensitive personal data) and also that you have told them who we are and what we will use their data for, as set out in this notice. In the case of personal data, with limited exceptions, and on payment of the appropriate fee, you have the right to access and if necessary rectify information held about you. In assessing your application, the insurer may undertake checks against and publicly available information (such as electoral roll, country court judgements, bankruptcy orders or repossessions). Similar checks may be made in assessing any claims made. Information may also be shared with other insurers either directly or via those acting for the insurer (such as loss adjusters or investigators). Sensitive Data In order to assess the terms of the insurance contract or administer claims that arise, the insurer may need to collect data that the Data Protection Act defines as sensitive (such as medical history or criminal convictions). By proceeding with this insurance, you will signify your consent to such information being processed by the insurer or its agents. Claims History Under the conditions of your policy you must tell us about any insurance related incidents (such as fire, water damage, theft or an accident) whether or not they give rise to a claim. When you tell us about an incident we will pass information relating to it to a database. We may search these databases when you apply for insurance, in the event of any incident or claim, or at time of renewal to validate your claims history or that of any other person or property likely to be involved in the policy or claim. You should show these notices to anyone who has an interest in the insurance under the policy. Choice of Law The Law of England and Wales will apply to this contract unless: 1) You and the Insurer agree otherwise; or 2) At the date of the contract you are a resident of (or, in the case of a business, the registered office or principal place of business is situated in) Scotland, Northern Ireland, Channel Islands or the Isle of Man, in which case (in the absence of agreement to the contrary) the law of that country will apply.

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